ACC/SCN Statement on Nutrition,
Refugees and Displaced Persons

The ACC/SCN considered the position of refugees and
formulated a statement, the specific recommendations of which are
that:

a) the protection and promotion of the nutritional well-being
of affected populations be fundamental goals of agency policy and programmes
concerning refugees and displaced persons;

b) the roles, responsibility and accountability of different
organizations, and levels within organizations, be reviewed and if necessary
re-defined;

c) routine monitoring of affected populations to be mandatory,
in terms of quantity and quality of food supplied and consumed, anthropometric
status, the presence of specific nutritional deficiencies, and
mortality;

d) reports on these matters be made regularly through the UN
system to donor governments and UN governing bodies, which themselves should be
more probing in asking questions;

e) NGOs, together with UN agencies and host governments, be
recognized in practice, as well as officially, as legitimate partners in these
processes;

f) the results of monitoring the operation and impact of
relief (see c above) should have an immediate influence on the management of
relief operations in terms of action to improve nutritional
well-being;

g) management should encourage flexibility and - coupled with
accountability - devolution of responsibility for decision-making to
intermediate and local authorities;

h) agencies should strengthen if necessary their technical
capacity, and give due attention in their decision-making to nutrition and other
technical considerations;

i) this process should include, at an early stage, decisions
on appropriate goals in terms of alleviating malnutrition and specific nutrient
deficiency diseases among refugees and displaced persons.

Protecting Refugees' Nutrition with
Food Aid

Mike TooleCentres for Disease Control

Introduction

The number of refugees dependent on international assistance
continues to increase rapidly; of the world's 18 million international refugees,
approximately 13 million are living in camps in remote areas of Africa, the
Middle East, and Southwest Asia. In addition, up to 20 million internally
displaced persons are dependent on some kind of international food aid for their
survival. Surveys of these populations have demonstrated wide variation in both
early nutritional status and in the rate of improvement that has resulted from
international food assistance.

The Problem: Protein-Energy Malnutrition

Acute undernutrition prevalence rates have been elevated in
many displaced and refugee populations during the past 12 years, ranging as high
as 50% in eastern Sudan in 1985 (Tables 1 and 2). Even in 1991, rates
were as high as 29% in Kenya, several months after Somali refugees arrived in
that country. Undernutrition rates have decreased rapidly in situations where
effective emergency relief operations have been mounted promptly, such as
Thailand (1979) and Pakistan (1980); however, in other emergencies, such as in
Somalia (1980) and Sudan (1985), undernutrition rates have remained high
(>20%) for 6 to 8 months. Of even greater concern is the observation that
acute undernutrition rates among Somali refugees in Ethiopia (1988-89) actually
increased 6 months after a relief programme was launched.

Table 1: Prevalence of Acute Undernutrition among children
less than 5 years of age in refugee populations.

Dates

Host Country

Country of Origin

Population

Prevalence % Undernutrition

1979

Thailand

Kampuchea

31,900

10.0-18.0

1980

Somalia

Ethiopia

700,000

21.7-28.4

1984-85

Pakistan

Afghanistan

2,500,000

2.3-3.5

1988

Malawi

Mozambique

400,000

2-1-6.1

1988-89

Ethiopia

Somalia

400,000

12.9-29.5

1990

Guinea

Liberia

400,000

5.3

1990

Ethiopia

Sudan

25,000

45.0

1991

Kenya

Somalia

50,000

29.0

1991

Iraq/Turkey Border

Iraq

400,000

4.1

Table 2: Prevalence of Acute Undernutrition among children
less than 5 years of age in internally displaced populations

Date

Country/Region

Population Affected

Prevalence Acute Undernutrition

1983

Mozambique

12-28%

1985

Ethiopia (Korem)

800,000

70%

1988

Sudan (Khartoum)

750,000

23%

1988

Sudan (S. Darfur)

>80,000

36%

1990

Liberia (Monrovia)

500,000

35%

Malnutrition and mortality

While most high acute undernutrition prevalence has been
associated with inadequate food rations, it appears that malnutrition developed
among Kurdish children 1 to 2 years of age in Turkey within a period of 1 to 2
months, primarily because of the high incidence of diarrhoeal diseases in the
camps. The synergism between high malnutrition prevalence and increased
incidence of communicable diseases explains much of the excess mortality seen in
refugee and displaced populations. A study of 42 refugee populations in 1989
showed a strong positive association between acute malnutrition prevalence and
crude death rates (CDR). Populations with acute undernutrition prevalence rates
of less than 5% had a mean CDR of 0.9/1000/month. Refugee populations with
undernutrition prevalences of >/= 50%, however, experienced a mean CDR of
37/1000/month with a range of 4/1000/month to 177/1000/month.

The close correlation between malnutrition prevalence and
crude mortality during a relief operation for Somali refugees in eastern
Ethiopia in 1988-89 was clearly demonstrated. Malnutrition prevalence was
estimated by serial cross-sectional cluster sample surveys of children less than
5 years and monthly death rates were estimated retrospectively by a
population-based survey in August 1989. During the period of high malnutrition
prevalence and high mortality (March through May 1989), the crude death rate
reached 9/1000/month - 4.5 times greater than the non-refugee death rate in
Ethiopia. Food rations provided an average of approximately 1400 kilocalories
per person per day instead of the recommended minimum of 1900 kilocalories per
person per day.

Likewise, in eastern Sudan in 1985, inadequate amounts of food
(1360-1870) kilocalories per person per day) were distributed to Ethiopian
refugees during the first five months after their arrival in the camps.
Malnutrition rates, as well as mortality rates, remained high during this
period.

The importance of micronutrient deficiencies in refugee and
displaced populations has only recently been extensively documented. In addition
to deficiencies of vitamin A and iron, conditions that have been widely
recognized as important childhood problems in developing countries, large
epidemics of scurvy and pellagra have also been reported in refugee populations
during the past decade (Table 3).

The international community has still not developed an
adequate strategy to prevent scurvy in refugee camps in the Horn of
Africa, as demonstrated by an outbreak that took place among adult males (former
Ethiopian soldiers) in a camp in eastern Sudan during 1991. Scurvy has been
closely related to the duration of stay of refugees in remote, African camps (in
particular, those for Ethiopian refugees) where food rations have been confined
to two or three items. The vitamin C content of these rations has been far below
international recommended daily allowances.

An outbreak of pellagra occurred in Malawi among Mozambican
refugees between July and October 1989, with 1,169 cases reported in 11 camps
where the French agency Médecins Sans Frontières (MSF) was
providing assistance; 20% of the cases were in children under 5 years of age.
Another outbreak occurred between February and October 1990 with 17,878 cases
reported among 285,942 refugees in the same 11 sites, for an attack rate of
6.3%. More than 18,000 cases were reported from all districts hosting
approximately 900,000 refugees in southern Malawi, for an overall attack rate of
2.0%. Food rations contained an average of 4.9 mg of available niacin per person
per day; the FAO/WHO recommendations for niacin range from 5.4 mg for infants to
20.3 mg for adults. This outbreak occurred when relief efforts failed to include
an adequate supply of groundnuts, the major source of niacin in refugee
rations.

The lack of variety in basic relief rations is a significant
risk factor for pellagra and other micronutrient deficiency syndromes. The
inclusion of groundnuts or fortified cereals in daily rations increases the
total intake of available niacin and will prevent the development of
pellagra.

Risk Factors for Pellagra in Refugees in
Malawi

- Young age- Femalesex- Absence of groundnuts or fish in diet- Unemployed head of household- Residence in camp (rather than integrated
village)- Absence of home vegetable garden or poultry

Solutions

The adequacy of the international response to refugee
emergencies has been inconsistent, based more on political considerations than
on real needs. The avoidance of high malnutrition rates and excess mortality in
eastern Thailand (1979) and Pakistan (1980) was probably related to the
political importance given to those refugee populations (Cambodians and Afghans)
by major donors. In addition, logistical constraints were relatively minor in
those countries - both Thailand and Pakistan had important food reserves that
could be tapped and fairly good communications and transport
capabilities.

The real problems lie in Africa, in particular the Horn of
Africa where logistical problems are great and where the political interest
among donors is less pronounced. Nevertheless, there have been some
successes.

Widespread protein-energy malnutrition was avoided among
Liberian refugees in Guinea in 1990; perhaps, we can than the generosity of
local Guinean villagers rather than the promptness of the international
response. In Malawi, acute undernutrition rates have been low; however,
international food aid has been insufficient to avoid large outbreaks of
pellagra.

Refugees require the same range of nutrients as other human
beings for their survival. The basic human nutrient requirements have long been
adequately defined and international guidelines have long existed. If the
international community is serious about the protection of refugees, then there
has to be an international commitment to protecting refugees from preventable
diseases and death. Both protein-energy malnutrition and micronutrient
malnutrition among dependent refugees can be readily prevented by the prompt
provision of a basic food basket sufficient in quantity and quality. the world's
response to refugee and other international emergencies needs to be consistent,
based on sound technical assessments, and systematically evaluated to ensure
that food and other humanitarian assistance produces the desired impact on the
affected population.

There are real practical constraints; the logistics involved
in providing an adequate ration to the remote regions of Sudan, Somalia, and
Ethiopia are indeed formidable and costly. Regional food reserves, innovative
food purchases and exchanges between neighbouring countries, and the use of
fortified cereals to provide micronutrients would expedite the prompt provision
of adequate food rations. My recent experience with the situation in Russia,
however, has taught me - once again - that our political leaders have not yet
committed themselves to needs-based humanitarian assistance. Photo opportunities
and short-term political agendas continue to dictate the nature of our response
to food-related and public health emergencies. Change will only occur if there
is a high-level agreement to provide basic human needs to emergency-affected
populations, enforced by the type of international conventions that are meant to
protect civilians in time of war and which govern the use of nuclear weapons. I
will close by proposing a modest goal for the international community to adopt.
By 1995, in any displaced or refugee population of 10,000 persons, anywhere in
the world, no more than 50 persons should die during the first month of their
displacement.

Comments

John Seaman

Save the Children Fund, UK

Dr Toole has made a very solid and well documented case for
the very poor conditions of refugees, particularly in Africa.

My discussion begins with two preliminary points. Firstly,
refugees have a very special status in the world, in countries which are
signatories of the Refugee Conventions. There is a responsibility, morally, if
not in international law, to see that refugees are well treated. Secondly, as Dr
Toole pointed out, food requirements of refugees are not special to refugees. I
would like to discuss this further, although it seems obvious, because there has
been a great deal of discussion over many years about the recommended ration --
how much food a refugee requires - and there have been endless meetings on this
topic, which so far have not reached a completely solid conclusion. There are UN
documents recommending rations of 1900 kcals, and I believe the EEC has also
moved to introduce the same standards. But there is as yet no general
international agreement that refugees have the same food requirements as
everybody else, and that these food requirements should be met. To be fair to
the UN, I think that one of the reasons for this is their concern that setting
standards on food requirements is quite different from actually getting the food
delivered, and that if the donors are only providing food from intervention
stocks, they are never going to meet such standards. At the same time I think it
is very late in the century, and there are, as Dr Toole pointed out, rather a
lot of refugees in the world, to still be discussing whether a refugee requires
1900 kcals or 2200, or indeed, as has often been the case, whether one can get
away with 1500 or less.

Dr Toole talked about logistical constraints in getting food
through to refugee populations. Whilst there is no doubt that these problems
exist in remoter areas where refugees are found, we should be careful not to
regard this as an easy excuse for inaction. There are very few parts of the
world, even in the remoter parts of Africa, which cannot be reached with
reasonable effort. In fact, if we take some of the worst cases where refugees
have starved, or where refugees have suffered from serious nutritional
deficiencies, these have been in countries where logistical difficulties were
minimal. There was a case less than a year ago in Sudan where foodstuffs had
arrived in the main port, but failed to be delivered to their destination about
half a day's drive down a good road. We have a current case in Kenya where the
markets are full of food, the budgets are perfectly adequate to buy the food,
where the ports are good, the roads are good, but somehow the food has not been
delivered.

Dr Toole discussed the problem of inadequate and unsuitable
food rations. Could fortification help? Fortification seems a very easy option,
but in practice it has turned out to be rather difficult. One option is to
fortify donor foods at source, but because milling grains before they are sent
has disadvantages - such as reduced storage life and the added cost of bagging
the cereals -the problem is how to fortify whole grains? I believe there is a
technology available to do this, but it is expensive which would add a
considerable amount to the cost of the foods concerned. If fortification is
carried out at local level, again there are difficulties. Camp-level
fortification has been tried. Cement mixers full of skimmed milk with vitamin C
powder have been used for fortification for local use. However, this is not
practical in the long-term in large populations if you consider the tonnages
involved - the number of cement mixers needed would be very large, as would be
the required administrative control. It would not work. The only situation that
we have found so far where we have been able to introduce fortification is in
Malawi where there is a sophisticated local commercial milling capacity. It has
been possible to successfully add niacin to maize meal, and we should be
fortifying most of the rations by next year.

Another concern we have about fortification is that, although
the current food technology is effective, donors are clearly not enthusiastic
about spending large amounts of money on refugees. In the Malawi case, we have
already made some effort to see if we can add further nutrients to the maize
meal ourselves, and fortification with iron, zinc, and vitamin C has been
discussed. Would it be possible, in fact, to get a cocktail of all nutrients and
add it to maize meal? We are reluctant to pursue this route for the obvious
reason that, although it might be technically possible to keep populations on
maize porridge and nothing else, people should be able to get food roughly in
the form that they are familiar with and like - a diet is as important as
nutrients. Fortification is a fix. It has its place, particularly in the case of
B vitamins, but I think that we should not lose sight of the fact that we should
be aiming in general to provide foods adequate in terms of quantity and
quality to refugees.

Then there is the question of diversification of income. Under
some circumstances, refugees may have possibilities of producing their own food.
It is true that in many parts of the world, refugees do produce their own food -
and in some cases have maintained themselves for many years without any
international ration provision at all. But we should not lose sight of the fact
that there are large numbers of refugees in parts of the world where this is
really not a practical consideration, particularly the semi-arid and arid zones
of East Africa where there are large concentrations of refugees - sometimes
30-50,000 - in one place. There really is very little that they can do to secure
an additional food supply; they are completely dependent on international
gifts.

Dr Toole mentioned the apparent lack of political interest,
particularly with regard to Africa, and I think there is no doubt that this
exists. Recently, I was involved in discussions concerning a particular case of
refugees in East Africa which attracted quite a lot of media attention. It was
pointed out that two years ago, the State Department would have wanted to know
what was going on. Now, no matter how publicized the situation is, nobody really
seems to care about what's happening to Somalis in Kenya. On the other hand, the
fact is that aid flows to Africa for refugees are very substantial. Western
donors are giving enormous amounts of foodstuffs to some African countries, much
of which is going to refugees. Therefore, although in political terms, there is
less pressure to put up the money, the fact is that there is still a great deal
of goodwill and a very considerable flow of resources. Why, then, do we
repeatedly have these problems in Africa? - problems which, as Dr Toole pointed
out, amount to outright starvation in some cases, and great epidemics of
diseases which have not been see in epidemic form for a century. Surely there
has to be some explanation - if we have got the food, if we have got the
markets, if we have got the logistics, and by and large we have got the money,
what goes wrong? At Save the Children Fund, we have been searching for the
reasons very carefully - over a number of years in many cases - and we have come
to conclusions which are of a rather more humble and bureaucratic nature than
the conventional conclusions. The problems really come down to accountability,
and monitoring and evaluation.

If we look at the international law relating to refugees, the
one thing that is clear is that UNHCR has no responsibility whatever for the
material welfare of refugees. They can act as a conduit for international
assistance - they can act of their own volition if they wish - but they have no
legal responsibility for the material welfare of refugees. This situation
appears to have its origins at the time that refugee conventions were first
drawn up after the Second World War when material welfare was not a major
consideration. It was an honest piece of legislation and it was drawn up chiefly
for refugees in Europe, where countries were poor, but were able to materially
support refugees. The overriding consideration was political protection and the
legislation was drawn up in those terms. What this legislation has led to is an
ambiguity of responsibility within the international system, and between the
international system and the host government of refugees. If any resident
representative of UNHCR is asked if he or she is responsible for the welfare of
refugees, the general answer is no. Who is responsible? Is the host government
responsible? How can the host government be responsible when the host government
is frequently bankrupt, at war, or having problems feeding its own population?
We seem to have a situation where nobody is responsible, and everybody is
responsible.

There are no measures of outcome. All the measures are
measures of process - dollars committed, tons committed, rations planned. We
have no measures within the system of rations delivered, rations dispersed in
populations, and nutritional outcome. There is no requirement for the UN,
donors, or host governments to actually monitor the conditions of refugees.
Assessments are done, but they are done intermittently. They are also, of
course, done by non-governmental organizations, which do not have the right to
report their findings within the international system. Documents presented, for
example, at UNHCR's Executive Committee, do not usually contain accounts of the
nutritional conditions of refugees - they do not contain accounts of scurvy, of
pellagra, of starvation. They are all about process, they are all about money,
they are all about law. Donors are not officially informed of nutritional
problems. Having looked closely at the system in several cases, and having been
a donor representative myself for some years, I am aware that donors frequently
simply do not know what is going on. We tell our donors what we know, and we
bypass the system, and sometimes that is helpful; but it is clear that any
system that does not have a measure of performance does not amount to a
system.

What we need urgently is the requirement that host governments
or UNHCR carry out a minimum monitoring of refugee standards and report that
back to donors. If donors then choose to do nothing, that is their right in
international law, but at least the donors would have been able to make a
choice. Currently, we have a situation where donors are only making a choice
when things go badly wrong and reports get into the media. We have had five
cases in the last 7 or 8 years where these situations have been brought to the
media, and on every occasion the situation has been put right. One case took two
years, but all the rest had been put right within the space of a few months. It
appears then that once donors are aware that they have a major problem, things
start to happen. It seems to me that if donors were aware that there was a
scandal - outside the newspapers and off the television - then actually this
would often secure action. Resident representatives would not be able to
experience these situations and not report them if they knew that a wider
constituency was aware of what was going on.

I would like to briefly discuss material supplies. I do not
think anybody really knows the truth, but there is a general consensus that
current commitments of material to refugee populations are sufficient in
quantity (although there is also the question of quality). On the one hand, we
know that many refugees essentially feed themselves from their own activities,
their own resources, their own work, and from agriculture. But quite frequently,
these refugees have been receiving full rations, for reasons such as lack of
information or political judgement. Afghan refugees have been mentioned as one
group who have been extraordinarily well served with food, housing, fuel and
cash over a long period of time, where cereals alone would suffice because
people could exchange them. At the other extreme, we also have situations where
people have nothing, and need rations for survival. There is a case to be made,
then, that if we were better supplied with information we would be able to
distribute the available food much more effectively.

Basra Hassan

Save the Children Fund, Sudan

Dr Toole's presentation very nicely summarized the major
nutritional problems refugees often encounter, and Dr Seaman has also pointed
out very important points regarding refugees and the problems they are facing. I
will highlight a few points from Dr Toole's presentation and paper, and make a
few remarks.

Table 1 of Dr Toole's paper must have been striking to some of
us -- to see that there are groups of refugees receiving adequate, well-balanced
diets whilst living or located in very inaccessible places - receiving what they
need through planes, whereas in places one can reach with trucks and spend a few
thousand dollars, people are starving, and not receiving adequate rations. Who
should be blamed for this? Is it the UN agencies, the donors, or those
governments? Dr Seaman has touched on this point. As a refugee from East Africa,
I really still require more explanation.

Dr Toole also discussed the nutritional status of refugees
deteriorating while they are in the camps - there were examples of increases in
the prevalence of protein energy malnutrition of under-5 children. In Somalia we
have also had experiences of refugees' nutritional status deteriorating while
they were in the camps. There was a outbreak of anaemia in children and women of
child-bearing age -- in 1986 we discovered that 44 women who were newly
delivered or pregnant had died within two months and we had 33 infants aged
between two weeks and one month with no mothers, in a camp with a population of
35,000. Before this happened we had contacted all the UN agencies who were
working with refugees in Somalia and informed them about the deficiencies in the
rations and the problems these would be likely to cause, but nobody took our
words seriously. However, when the situation began to deteriorate, and became
visible, a dramatic change took place, both in the ration quality and the
surveillance quality. The ration was improved in that beans were included on a
regular basis and canned meat was brought for all - to be distributed as a
supplementary ration for all pregnant and lactating women. More drugs of better
quality were provided. Iron injections were included in the regimen for the
treatment section. More tents were sent to open more in-patient clinics so that
we could admit the severely anaemic women. A liver programme was established
whereby all women whose haemoglobin was less than 7 g/dl were admitted, and
those who were not very weak and who could take things orally were provided with
150-200g of liver on a daily basis. Iron tablets and vitamin C were also
provided. Those who were unable to take the iron tablets that we were using at
the time received an iron injection in place of the tablets, plus the liver, and
those who were in a very serious situation, and who were in the last trimester
were given blood transfusions.

Extensive surveys carried out at that time showed anaemia
rates amongst children of 72% (cut-off of <10g/dl). We did not use the WHO
cut-off of 11g/dl, because almost everybody would have fallen under that
category. About 15% of the women were also severely anaemic. The subsequent
surveys that have been done have shown dramatic improvements in all age
groups.

I would also like to discuss the issue of rations - where the
main discussion focusses on the quality and quantity of rations. If you go to
the UNHCR or WFP offices in the countries which have refugees, their plans look
fine. They can show you the amount of ration recommended, and the nutritional
content of these rations, and these appear adequate on paper, but an important
consideration is the regularity of the supply. The UNHCR and WFP representatives
in the countries with refugees have been frustrated by the decision-making
process. Many decisions about rations require HQ approval, and representatives
will often tell you that HQ has not given approval, that someone important at HQ
is away, and that they have to wait. Time passes and the problems increase, and
there will come a time when little can be done about the situation. For example,
one time when the malnutrition rate in under-5 children was very high in the
camps in one region, we contacted the WFP representative, who told us that there
was a policy decision that only malnourished children should receive the
supplementary ration. We suggested that we give food to all the under-5 children
- at that particular time we had food which could feed these people for three
months - and we asked if it would be possible to speed up the arrival of the
next food supply. We were told that the representative could not do anything
unless the headquarters approved it. It is my opinion that similar things are
happening in other countries, and this irregularity of the ration supply causes
a lot of uncertainty and lack of faith on the part of the refugees.

The following is dialogue between two women, Miss X and Miss
Y. Miss Y went to a registration centre and when she came back she met Miss X on
the way.

X: "Where are you coming from?"Y: "I am coming from the registration
centre."X: "What did you tell them?"Y: "I told them about the members of the
family."X: "How many?"Y: "Nine"X: "You are foolish, you know. You are not intelligent
enough. Why did you not double the number?"Y: "I do not like lying and also it is against the
religion."X: "Do you want to starve the
children? There are times the religion allows you to tell lies when these things
touch on your survival."

So for refugees food is often survival, it is not for
development. Even when food was required for survival in Somalia, there were
times when some food was allocated to the development programme, and WFP were
not able to switch the food from the development to the refugee programme. So, I
wonder why we seem to be putting more emphasis on having good relations at
governmental level while people are starving and suffering when food is
available and could very easily we switched to those who need it most.

Another point that made by Dr Toole was the tackling of
problems such as scurvy by introducing vegetable gardening and fish farming,
etc. I do not think this can be applicable to all situations. For example, the
Kenyans would be very happy if the Somali refugees in their country confined
themselves to their wired area. And the camp is so crowded that vegetable
gardening or any other kind of farming is simply not possible.

Scurvy was a big problem in Somalia, and a number of options
have been tried in order to tackle the problem. One of them was the mass
distribution of vitamin C tablets, and we found out that this was impractical or
impossible. The whole staff working for the refugee health section would have
spent all their time just distributing and counting the tablets. The other
problem we faced was misuse of the tablets. For these people, tablets and
medicine are only for the sick, and although we had offered a lot of education
on the subject of who should take the tablets and when the tablets should be
taken, people were still using them for headaches and for use when they were
sick. We found many tablets just thrown away, and children were taking tablets
meant for family members. If children liked the sour taste of the vitamin C,
mothers would just give everything to the child rather than sharing them as
prescribed. There was a lot of misuse and abuse related to the vitamin C
tablets. The other thing we tried was distribution of grapefruits and limes and
that was also impossible because of the logistics involved - a great deal of
money was required to make this work.

We also thought of fortifying dried skimmed milk (an item in
the ration) with vitamin C powder - as Dr Seaman has mentioned. For the first
three weeks it seemed that it was working and the milk itself was acceptable -
there were no complaints about the taste. We also did laboratory analysis of the
fortified milk. Unfortunately, the whole project had to stop because of war and
other problems in the country, and we were unable to assess extent of its
success.

I would like to end my discussion by saying that for refugees,
the UN is their parent, particularly the UNHCR and WFP people. They should think
of themselves as the fathers of their families. A concerned father who left his
children at home knowing that there was nothing left to feed them would think
about and be very concerned about how he would feed his family, unlike a father
who is not concerned. What is the use of a father who cannot feed his
family?

Rita Bhatia

UN High Commissioner for Refugees

Dr Toole's presentation has shown that over the last ten years
we have been seeing high mortality, high malnutrition and outbreaks of
nutritional deficiency diseases, and Dr Hassan has discussed the dependency of
refugees on international aid. Very recently, when I was in Ethiopia, a refugee
came to me - a woman - and told me "the distribution point is my field and the
ration card is my hoe". Refugees can be totally dependent. Even if they are
peasants, that's where their food and living is.

I would like to discuss another very recent case study. In
Sudan, we had about 20,000 - 30,000 male Ethiopian soldiers and ex-soldiers from
the Ethiopian regime who took asylum in Sudan and were totally confined to a
closed camp for over three weeks. They arrived in a good state of health, but
soon developed scurvy, vitamin A malnutrition, and high mortality. There was
very little water. They had access to only a small amount of cereal which was in
the form of whole grains as there were no milling facilities. This population
was totally dependent. At the end of this period, the soldiers were repatriated
to Ethiopia, and the statement was made that this was one example of a
successful repatriation of asylum seekers or refugees back to their home
country. Nobody looked into what happened during the process.

What is wrong then? Why have we been going through these
repeated failures? Is it due to lack of political will? Is it due to lack of
resources? Is it due to poor management organization of relief services? From my
own experience, and having been in the UN for a while, I do feel that there is a
big communication gap between the technician and the policy-makers. Most of the
food aid which is sent comes from the western world, and refugees can be totally
dependent on it. We have very little choice about types of commodities, because
aid is not in the form of cash - it is in the form of food - and so we have
inadequate supplies, both in terms of quantity and quality. There has been
inconsistency in the international response to many of the refugee emergencies,
which is often based on political considerations and not on real needs. As we
all know, refugees are dependent on this food aid. They often do not have access
to markets, or to other barter systems, and what we give them is not enough to
meet their needs. The consequences are obvious.

I would like to briefly mention logistical difficulties. As Dr
Seaman said, even in some of the remotest places, logistical difficulties can be
overcome. In Turkey and Iraq, because there was a political will, the logistical
problems were solved by the use of helicopters and all kinds of planes. If there
is a political will, I think there is a way. Logistics should not be used as an
excuse for not delivering aid in adequate quantities and quality.

As Dr Seaman mentioned, there has been some agreement between
the UN agencies, especially between UNHCR and WFP on basic minimum requirements.
1900 kcals has been recommended as the minimum requirement in emergency
situations, but we have seen that people have been given less than half of that
amount. In terms of the quality of food, which has already been mentioned by all
my colleagues here, scurvy has been seen as a problem among refugees alone. I
would like to address this issue again. Many experts have been doing a lot of
work on vitamin A, anaemia and iodine, but there is no international strategy on
prevention of scurvy. Pellagra is another micronutrient deficiency which has
been seen in Malawi, among Mozambiquan refugees. Therefore, I would very much
encourage and ask the group here to look into other micronutrient deficiencies,
and not just to focus on the three or four major micronutrient deficiencies
which have been discussed for the last ten or twenty years.

As technicians, we should be aware that our role is also to be
advocates for refugees in terms of presentation and dissemination of
information. Technicians should focus their advocacy efforts on promoting
outcome oriented relief resources and assistance. As has been pointed out, there
is no system whereby anyone can be held accountable if the proper information is
not available. I think ongoing monitoring evaluation is very important, not just
on the part of the UN, but also on the part of our other implementing
partners.

I also feel that monetization should be encouraged among
refugees, perhaps not in every situation, but in some situations where they have
access to the market. One recent example is from Indonesia, on a small island
where there are 20,000 Vietnamese refugees. They have free access to the
markets, and they can go out of the island on the weekends. These kinds of camps
are semi-closed. People are able to go out and look around. Thus, there are some
situations where monetization should be tried and donors should be more open and
flexible about who should be given cash - not for the whole food basket, but for
perhaps some of the commodities which are available in the markets.

Another issue I would like to discuss is that of buffer stocks
in the regions, which could be in the form of cash or in the form of kind. WFP
has tried to set up regional stocks of food, but it did not work out very well
because of logistical problems and infestation of food items. One suggestion
which I would like to make is that perhaps buffer stocks of cash be set up. With
cash one can easily go out and buy some of the required food items, and this way
the normal procedure of UN which involves waiting for a green light from
Headquarters could be avoided, and the procurements could be made at regional
level.

Statement to Organizational Committee,
27 March 1992, by John Mason, Technical Secretary, ACC/SCN, Concerning the SCN's
Report on Nutrition, Refugees, and Displaced Persons

"The SCN had first become aware of the nutrition crisis
amongst refugees because of a conference held in 1988, organized by WHO and
UNHCR, under SCN auspices. This conference had been aware of the difficulties of
meeting refugees' nutrition needs, and had put forward a statement to the SCN,
which subsequently went to the ACC. I will quote briefly from this statement. We
said that the problem with famine and disaster had resulted in unprecedented
numbers of people depending for their survival upon international food aid,
sometimes for prolonged periods of time. It was noted that although the total
volume of emergency resources had been generous, this had nonetheless proved
painfully inadequate to meet escalating needs, and indeed had at times failed to
reach the intended beneficiaries due to severe constraints in recipient
countries. The meeting noted that consequently the rations provided very often
result in a seriously insufficient and unbalanced diet.

"The SCN had requested the ACC to bring this tragic situation
urgently to the attention of donor governments. I am glad to be able to inform
the OC that we understand that this did indeed have some effect. The statement
was passed from ACC to ECOSOC and thence to a number of member governments, and
we understand from participants in the SCN that some awareness had been raised,
and indeed some action taken.

"The Sub-Committee had been kept aware of the nutrition crisis
in the period since 1989, and at the Symposium held at the World Food Programme
at the time of the recent Session in February, one of the three themes was
protecting the nutrition of refugees and displaced persons with food aid. During
this part of the Symposium, the Sub-Committee heard reports that nutrition in
refugee camps was no better now than it had been the last time the situation was
considered. It heard of increasing numbers of refugees certainly, so that with
no improvement in the prevalence of malnutrition, the number of people suffering
must have increased significantly.

"Perhaps the most shocking information for the Sub-Committee
were two aspects. First was that during refugees' slays in camps, in sight of
help, people remained or become severely underfed, and some died as a
result.

"Secondly, that epidemic outbreaks of micronutrient deficiency
diseases - scurvy, pellagra, beri-beri, which were thought to have been
eliminated in the world - were now re-emerging.

"In the serious discussion that followed, the Sub-Committee
focussed on two improvements in the system. The first of these was to improve
the clarity of the accountability, who is responsible for this situation and
more important who can prevent it happening. Secondly, and related to this,
monitoring systems need improvement. It was said that although more resources
were needed, it was also the case that better use of resources would be
feasible, if the necessary information was available, and the necessary
decisions were made. It was noted that all too often information got attention
through mass media, and then necessary decisions were made: this could be
greatly improved to ensure, as the statement says, "a more timely and effective
response to the nutritional needs of refugees and displaced persons".

"It was felt that the SCN was an appropriate forum to identify
such deficiencies - there was a collective need to take urgent action, without
singling out anyone's particular role.

"These specific recommendations were carefully thought out and
worded - as was the whole statement - initially by a group led by UNICEF,
drawing on SCN members, and then reviewed by the SCN Executive Session, and the
Subcommittee in plenary. The specific recommendations refer most of all to
monitoring, and reporting to those who can take action and be accountable for
that action. They include the setting of goals for alleviating malnutrition
among refugees and displaced persons.

"The SCN had listened to Ms Basra Hassan, a nutritionist from
Somalia who had contributed to the 1988 meeting, and who is now working in
Darfur, Sudan, for Save the Children Fund. She herself had recently been a
refugee from Somalia. She said: "You have to realize that the UN is seen as a
parent to refugees - who else is there? And what use is a parent who cannot feed
their children?"

"Finally, the Sub-Committee recommended - appealed might be a
better word - to the ACC through the OC to help."